Healthcare Provider Details

I. General information

NPI: 1841349941
Provider Name (Legal Business Name): SOUTHWEST HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ISLETA BLVD SW
ALBUQUERQUE NM
87105-3896
US

IV. Provider business mailing address

111 ISLETA BLVD SW
ALBUQUERQUE NM
87105-3896
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-9550
  • Fax: 505-247-8950
Mailing address:
  • Phone: 505-242-9550
  • Fax: 505-247-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2006-0033
License Number StateNM

VIII. Authorized Official

Name: DAVID BALDWIN
Title or Position: PRESIDENT
Credential: PA
Phone: 505-242-9550